Merry Christmas 2010!

Merry Christmas and a happy new year, good luck for all that 2011 brings! 

Save a Life in 5 Minutes

At Heathrow airport all you need now is 5 minutes to learn how to save a life. I saw this video on the BBC News website and thought it was a great initiative by the London Ambulance Service which could probably be rolled out to a greater number of people. In particular, I thought that it was a good idea including a demonstration of using a defibrillator. It seems that there's still a widespread opinion amongst the lay public that the 'old-school' paddle set-up and the whole 'clear' then 'shock' method as performed on TV is still being used.

Using a defibrillator is something which anyone who can do. It's really not that hard. A lot of busy places now have defibrillators available but there may still be people who are not trained how to use them. CPR and chest compressions is all about buying time, but really if a patient has a shockable rhythm, then access to a defibrillator as fast as possible is what is required. It was interesting talking to Helen Brady this week, who runs the Heartstart in Dundee, that defibrillators have now been included in Heartstart training videos shown at teaching sessions. The defibrillator has simple diagrams, instructions and a voice to tell the user how to use it. I'll put my hand up and say that I have not been needed to use one in a 'real-life' situation, but having done some training and used the defibrillator in a mock set-up, I would certainly feel confident about using one in a life-saving situation.

End of Life Assistance Bill and PCOS Discussed

This week the Scottish Government voted overwhelmingly against the End of Life Assistance Bill in parliament. It's interesting that when I started at medical school 6 years ago, euthanasia was a topical subject, and it still is today. As with many difficult ethical dilemmas, no doubt this is a subject which will come up time and time again over the next 100 years. The End of Life Assistance Bill was thoroughly studied and discussed by an ethical board consisting of doctors, legal experts, religious groups and experts from countries where end of life assistance has been legalised, such as in the Netherlands. I think it is possible to see where the arguments FOR the bill exist ie. not to prolong suffering, beneficence (doing good) etc. However I believe that there are few doctors out there who would agree to be involved in the process of assisting someone to die. The main reasons why the bill was rejected were because of a fear of how the system could be abused and the doubt as to whether there really was any need to change the current system. I'm going to sit on the fence with this one as I don't think there are good enough arguments for either side to have a majority. Besides, sometimes sitting on the fence is the best place to take a good look at the bigger picture.

When the post did finally arrive today for the first time in over a week, one of the things which dropped through the letterbox was this month's student BMJ. The editorial and center articles were about the shortage of jobs predicted for foundation programme applicants this year. We find out on Wednesday this week how we got on in our applications so fingers crossed for a good score. There were a couple of interesting edicational articles such as this one on Polycystic Ovarian Syndrome. This condition is the commonest cause of anovulatory infertility in women and affects up to 10% of women of reproductive age therefore it is common. There are several pathological abnormalities in the condition such as abnormal ovarian morphology, insulin resistance and increased androgenicity. It is recognised as a diagnosis of exclusion. Patients with clinical features matching the condition should have other endocrine abnormalities ruled out such as Cushing's syndrome and adrenal hyperplasia. The management of the condition is complex and requires consideration of subfertility, metabolic consequences such as diabetes and obesity, and symptoms of hyperandrogenism.

SNOW DAY. Lessons on Improving Patient Safety.

This was the photo that made page two of the Dundee Evening Telegraph tonight thanks to our resident journalist Katie. A short clip about the 'avalanche' of snow which fell of the roof of the house and bashed in the roof of the car. Luckily I was able to push out the roof from the inside back into shape but a good story none-the-less! Shame about the neighbour's car whose back windscreen wiper snapped right off though.

I'm into the second week of the Improving Prescribing Theme SSC at the moment and much of the emphasis on the first week has been patient safety and reporting of errors. This is an important topic because a study in 2001 found that 12% of UK hospital admissions involve some form of adverse event. People never make mistakes intentionally but they are a common occurrence, even in the top medical institutions. Much of the time the mistakes come down to faults in communication and it's important to emphasise that it is nearly always the system which is at fault rather than individual blame. In the past there was much more of a 'blame and shame' culture of reporting errors however this has now changed with an increasing shift towards open reporting of incidents. One way to think about the way errors to occur is to imagine the 'Swiss-Cheese Model' where an adverse event occurs when a series of holes in the system are breached.

Ways of investigating an incident can include a 'Root-Cause Analysis' which is often started using a simple 'fish-bone' diagram. The factors to consider in how an incident occurred include:

1. Patient Characteristics
2. Task Factors
3. Individual Staff
4. Institutional Context
5. Work Environment
6. Organisation and Management
7. Team Factors

After considering each of these areas in turn, it is then possible to get an idea of the bigger picture of what led to an event occurring. We've been set a task in a small group to investigate an incident on one of the wards in Ninewells where an error was made an a patient was prescribed an overdose of an anticoagulant. During this week we'll meet as a group to discuss each of the factors in turn and then generate a report. Hopefully the plan will then be that once we have made our report, we'll be in a position to make a recommendation on how practice can be changed to stop this kind of incident from happening again. It's been an interesting course so far and will hopefully continue this way, unless the snow interferes too much! I'd advise anyone interested in this to look at the IHI Open School Website for more information.

Slip, Slop, Slap

I've started writing a case discussion on the subject of health promotion and disease prevention. Since I'm on a Dermatology placement at the moment, it seemed that writing about skin cancer would be the way to go. Rates of malignant melanoma have tripled over the past 20 years. The main reason why people think that may has been the case is the increasing tendency for people to travel abroad for holidays. With so many cheap flights abroad, its no wonder that people with fair skin are taking in more unaccustomed high intensity UV light. In order to try and curb this trend, there have been some pretty good health promotion campaigns to go ahead, led primarily by Australia, the country with the highest rates of melanoma in the world. In Australia one in twenty five men will get a malignant melanoma in their lifetime. The best known campaign was the 'Slip, Slop, Slap' campaign launched in 1981. The idea was to slip on a t-shirt, slop on sunscreen, slap on a hat. Since 1981 rates of melanoma have increased in Australia however the widespread uptake of this campaign has almost certainly slowed down the progression and increased public awareness of the disease. Here in the UK, the public health campaign is led by the British Association of Dermatologists and Cancer Research UK. It'll be interesting now to read more and find out exactly how much of a difference the UK campaign has made since it started.

Treating Obesity

Happy Halloween! The clocks go back this weekend so it's also the start of winter - officially. Had no idea what to write about this week, a medical student was accused of being behind the plot to blow up a plane bound for the US, I heard on the radio that they're hoping to invent an alternative to the contraceptive pill which involves rubbing cream into your thighs, and David Nutt has announced that alcohol is more dangerous than heroin (albeit on a population scale).

An article in the Sunday Times this weekend highloghted the ongoing debate over availability of drugs and the catch phrase 'post-code lottery'. The headline read 'Call for Banned Obesity Drugs Re-Think'. There have been calls in Scotland for the NHS to re-instate treatments for obesity despite evidence of the risks involved which include 'heart problems and depression'. In January the NHS chose to withdraw Sibutramine from the market, a drug which causes early satiety and can reduce food consumption by up to 20%. There is a growing feeling that relatively safe drugs are being withdrawn from the market because obesity is viewed differently to other disabling diseases without consideration for the physical, mental and social consequences of the condition. A whopping 10,500 people in Scotland are estimated to be on a daily treatment for obesity. Ribonamant was another anti-obesity drug withdrawn from the market in 2008 due to increased risks of suicide, and Orlistat which prevents fat absorption has unpleasant gastric side effects.

In the BMJ this week, the headline article was about surgery for obesity. NICE and SIGN have now published guidelines recommending bariatric surgery for specific groups of patients however many are still unable to gain access to treatment. NICE guidelines recomment bariatric surgery for patients with a BMI of greater than 40. A Cochrane review found that surgery was more effective than conventional management. the question that remains is should we be offering more bariatric surgery than is available at present? The surgery comes with its risks but the bottom line is that what was once considered an un-necessary and rare form of surgery is more and more becoming a leading treatment for obesity, at a time when obesity is reaching 'pandemic' levels in the UK.

PC Project Patient Meeting

I've just got back today from the European Pachyonychia Congenita (PC) Support Meeting 2010 which was in Edinburgh. I've never been along to a patient support meeting like this before but it was a great experience. The PC Project has now grown from an one person's idea to a worldwide support group for patients affected by the ultra-rare skin disorder. It is a keratin disorder caused by a genetic mutation, inherited as a dominant trait.

The best parts of the meeting were undoubtedly the discussion sessions. Several talks were given which were intended to be the springboard for discussion. It got very emotional at times, particularly in the Sunday morning session, where one of the mothers read out a selection of patient experiences. It was interesting to hear about how many people had lived for many years, some of them almost their whole lives without a diagnosis for their condition. Some had to just 'got on with it' while others were misdiagnosed and poorly managed by their doctors. With a condition as rare as PC, many consultant dermatologists will never have heard of the disease or seen a patient with the condition at all in their professional lives. Patients would often find that their doctors didn't know what their disease was and had to just take the advice they were given, these were the experts after all.

The PC Project enables a bridge to be made between research and clinical practice, now commonly known as 'Translational Medical Research'. It allows the people doing the lab work to find new treatments to meet the people who they are trying to help in an informal setting, and offers the opportunity for the patients to find out first hand about new developments and treatments for their condition. Although the PC Project is small, involving only a few dozen patients in the UK, I think that this kind of model could be applied to informing people about much more common diseases. It works particularly well for PC because most doctors do not know about the disease, therefore meeting the experts is really required for patients to have an understanding of the disease.

The whole experience was very rewarding, and it was great to put a human face to the name 'PC'. It puts some of the work that I did during my BMSc into perspective and gave me the chance to meet some of the people who may one day be receiving the benefits of all of the hard work that's gone into PC up until now.

October Reading Week

Spending the week in Kendal in the Lake District with Amy. Finally submitted my answers to the Foundation Application today, great to get them out of the way. Looking forward to enjoying the rest of the week, then its the second Glasgow clinical SSC, this time in Dermatology.

These doctors must have a low workload...

This made me laugh....Medic Guide: These doctors must have a low workload...

Treatment for Infertility and Latest News

This is the proposed logo for the project being worked on at the moment "The Scottish Universities Medical Journal" which I'm hoping will be developed over the forthcoming year with input from all of the medical schools in Scotland.

This week in the press was the awarding of the Nobel Prize for Medicine this year to Robert Edwards, the man credited with the discovery of in-vitro fertilisation. This treatment has helped over 4 million babies to be born around the world and now in the UK accounts for 2-3% of all new births. Although the process has been criticised from many religious groups, such as the Vatican, there is no doubt about the benefit this technology has been of to the huge numbers of couples every year who are infertile. It has been 32 years now since the first 'test-tube' baby was born in the UK and since then there has been a staggering increase in new developments, such as the development of intra-cytoplasmic sperm injection (ICSI) and pre-implantation genetic diagnosis.

Other topics which have been covered in the news have particularly relevant to me personally over the last couple of weeks. The most pressing is the news that there will be a shortage of foundation jobs for applicants this year. The waste of time, money and talent for any graduating doctor to be without a post next August seems pretty awful, particularly with the application process currently used. It seems that in the next few years an exam style application will be introduced whereby all applicants must complete the form within a set, short time period.

The new government is soon to introduce the true extent of the spending cuts which have dominated the headlines this year. News today is that students may be facing a 100% increase in tuition fees (certainly in England) and/or a new graduate tax. If this is brought in, it will hit students hard and I think many will drop out of university as a result. Medical students in particular (who take on longer, more intensive degrees and have less time for part-time work) will surely be the worst affected. Bringing in higher fees certainly goes against all of the work which the BMA has done in the past 5 or 10 years to broaden access to medicine. The next few weeks will be very interesting to see what happens and the reaction which will be taken to the proposed cuts.

Sunday 3rd October

Today marks the start of the Commonwealth Games in Delhi and I'm looking forward to watching as many of the events as I can over the next couple of weeks.

I read an interesting ethical article today with the title "Should you ever lie to your patients?" based on the 2007 article in the BMJ titled 'Can deceiving patients ever be morally acceptable?'
The author argues that in certain instances it may be alright to deceive patients. The example given is one where a patient is about to undergo surgery where their chance of survival is low, less than 50%, and asks the anaesthetist "Is everything going to be alright?". Should the anaesthetist in this situation tell the truth?

One argument is that you should never lie to patients and I agree with this message. Trust is a core element of the doctor - patient relationship and any form of deceit will fundamentally undermine this relationship. Lying to the patient would deny them of their autonomy, their 'right to know'. Should we always tell patients the truth, no matter how grim the outlook may be? Another option would be to take an evasive approach 'We'll do our best'. This however risks arousing suspicion and further upset the patient. Lying in this situation could be argued to be the most helpful due to compassionate reasons.

The obvious answer to this problem is that as with many ethical dilemmas, there is no right or wrong answer. Lying to patients is wrong and should not be done in any circumstances, however there may be situations where it may be in the patient's best interests not to know the whole truth and it may be more compassionate not to disclose information that could harm the patient (non-maleficence).

What can we learn from professional sport?

I watched with interest a BBC programme tonight on the detrimental effect of professionalism on elite sportsmen and it got me thinking about how it could also apply to doctors.

Professional athletes today have become more efficient, more driven and harder trained, with more facilities at their disposal than ever before in history. Some people spend their lives analysing sport, the perfect way to swing a tennis racket or golf club and the ultimate training regimes. Much of the time this is what drives people to the top to be the best, with every minute of every day fit for a specific purpose. But is this a damaging way to the top? Can this be sustained?

Some of the best sportsmen in modern day, are the ones who still look like they’re enjoying themselves. The ones who are happy with what they do and satisfied with their lives. For example I look at Roger Federer, Usain Bolt and Lionel Messi, athletes who still look like they keep some of that fun they had when they played as kids, before they signed their professional contracts, sponsorship deals and so on and so forth. Athletes who still lead healthy lives off the pitch, and I have no doubt, take time to get away from the game from time to time.

Compare these players to the ones we’ve seen fall from grace in recent times due to their disharmony off the pitch. The Wayne Rooneys and Tiger Woods. There can be no denying that their performance has been affected by things which have happened off the court. Tiger Woods is someone who looks as if his drive and obsessively hard-working approach has ultimately led to his divorce away from golf, and now his poor form on the course. Yes, he was one of the greatest golfers in history, but I doubt he will ever recover fully from the events of the past 12 months. People most often quote the astronomical salaries and immense pressures on England’s footballers as the reason for their failings in the world cup this year. There was never any doubt about the talent on the pitch, but at not one moment did the players look like they were enjoying themselves.

I think that this theory can be applied to medicine as well. It is often said that we are all our harshest critics, but maybe it’s important to take a step back from time to time. A happy doctor is a good doctor, we don’t have to be perfectionists to be good at what we do. I feel that the key to avoiding burnout is taking regular breaks from medicine from time to time, and keeping other interests away from the hospital wards. Medicine is a long, hard career and to make it all the way, this is the kind of doctor I will aspire to be on graduating from medical school next year.

Sunday 26th September

Pregnant women recreating Charles Ebbet's iconic photo 'New York Construction Workers Lunching on a Crossbeam'. The aim of the photo was help highlight the high rates of mortality amongst pregnant women who die every year in developing countries.

The topic which everyone is talking about at the moment amongst the 5th year medical students is that of job applications and securing a place on the UK Foundation Programme after graduation. According to early estimates it seems as if this year there is going to be a shortfall in places for the first time. The result of telling applicants this information is that people seem to be very anxious all of a sudden about what was previously considered a given, that on graduating from medicine all doctors would have a job. There have been angry letters from concerned students, reassurances from the professional bodies such as the BMA and lots of conversations had about this years applications process.

The application form is relatively simple, students apply to a foundation school eg ‘Scotland’, and then jobs within the region to which they apply. The application forms are scored out of 100, based on a combination of academic competencies and ‘essay-based questions’. These questions make up half of the application and answering the questions well is extremely important. I’m pretty sure though that given enough time and enough thought, it should be possible to score well on these questions.

Although the prospect of having unemployed doctors at the end of their medical training seems like a total waste of talent and money, the situation is the same for many UK university graduates at the current time and relatively, medical students are still lucky in the sense that most graduates from medicine will still have jobs in 2011. Primary school teachers have to put of with competition ratios in the region of 17 applicants per job and people are having to leave the UK to find work. It will be interesting come November this year to find out the exact number of applicants and whether or not there will be a shortfall in job numbers, but until then all I can do is take as much time and care as possible to fill in the application form and score highly on the essay based questions.

A Taste of Socialism in Cuba

I don't think I quite knew what I was getting myself in for by travelling to Cuba. I had an idea in my mind about what to expect. A spanish speaking country steeped in fascinating history and culture, distinctly different from the many of the countries around it. In truth, visiting Cuba is like going back in time about 50 years. It is quite refreshing that there is such a lack of Western culture and influence in the country. The streets are still crawling with classic US cars, many of the buildings have a distinct resemblance to how I would imagine the former soviet union to have looked like and the country is filled with tributes to the men who have helped develop Cuba into the country that it is today. In fact, the likes of Fidel Castro and Che Guevara are seemingly worshipped as Gods.

Cuba is still listed by the UK Foreign Office as a country of 'concern'. There are remain hundreds of political prisoners in Cuba and it is still possible to be thrown behind bars for opposing the communist regime. International human rights organisations such as Amnesty International are not permitted access to Cuba. And yet it seems such a contradiction that Cuba has one of the best medical health care systems in the world. Statistically there are more doctors in Cuba than there are in the whole of Africa. Cuban actually exports doctors in exchange for food and economic benefits from neighbouring countries such as Venezuela, the oil rich country with which is Cuba's largest trading partner.

I was surprised when I visited Cuba by the level to which the country is shut off from the western world. I witnessed thousands of students arrange at the University of Havana to hear Fidel Castro make his first public speech in 4 years, the majority of content of which was a lecture on the 'evil' powers America and the fact that the Amercians are putting the world on the brink of a nuclear war. My experiences in Cuba have given me an insight into just how fortunate we are in the UK to have access to information and freedom of speech. The personal impact of having my bag stolen from my hotel room on my first day of arriving of course left a bad taste for the rest of the trip, but in a way it further opened my eyes to what it's like to have things taken away from you, much like the population of Cuba have had things denied from them from most of their lives.

Spice Mas Carnival 2K10

It's the Wednesday after Carnival today so things are getting back to normal after the 48 hour street-party. Thought I'd share a couple of photos from the event. 2 are from the Soca Monarch Finals at the national cricket stadium on the Friday night last week and one is of some of the parade, passing the judges (on the balcony) on the Tuesday afternoon. I didn't have my camera for much of the event but Gordon B's got alot more photos to come.... I'm pretty sure that nearly everyone in Grenada turned out in St Georges over the past couple of days and we were there for pretty much the whole event (not much time for sleeping!). The main road routes through the capital are closed off for the whole event and the streets just become rammed with people following trucks blasting soca music as loud as you can imagine for 2 days straight, it's kinda hard to describe. Monday and Tuesday were both public holidays so no time for the hospital! I was expecting the wards to be swamped today after Carnival but actually things were relatively calm! The highlight of the carnival had to be getting up at 4AM and heading into St. Georges for J'Ouvert (the official start of Carnival on the Monday monring) with just some cash and old clothes, then getting covered in red paint and drinking rum till mid-day! Gordon B and I are now down to our last week in Grenada (can't believe it's gone so fast) so we're hoping to make the most of the last week on d'island!

Carriacou and Mid-Way Point

As far as the elective goes, this is the start of my 4th week so I'm half way through and it's flying by. Monday was a public holiday so had the day off. To make the most of it, a group of us went to Carriacou (Granada's little known sister island) in the Grenadines. It happened to be the weekend of the annual sailing regatta on the island so there was lots going on and a real buzz around the small island. We stayed in a great guest house called the green roof inn. The 1st photo is of sandy island where we spent a full afternoon on the saturday and the picture of us getting on the boat is actually the 'water-taxi' which took us from the mainland beach to Sandy Island. We only spent one night in Carriacou because Gordon and I were keen to get back to Grenada for more wreck diving on the Monday. We dove on the ship 'Bianca C', also known as 'The Titanic of the Caribbean' because she sunk on her maiden voyage. Whilst anchored in St. Georges, the capital of Grenada in 1961, an explosion in the boiler room caused her to catch fire. Everyone managed to get off safely and she was towed out to where she's currently resting in about 50 meters of water.

Back to the elective I've reached the mid-way point so starting to feel pretty familiar with the daily routines here and the way things work on the female and medical wards. I've got some company too now, a couple of elective students from Southampton have arrived (Jamie and Anthony) who are on the wards as well. I've started collecting data for an audit project I'm going to do on antibiotic prescribing and am looking for a couple of interesting cases to write up for my elective report. I want to write about sickle cell anaemia for one case because the disease is so prevalent here and the history that the first ever documented case of the condition was recorded here on this island. Also there's a large number of cases of Dengue Fever, otherwise known as 'Break-Bone' Fever on the wards at the moment which could be worth writing about.

If you're reading this I hope you're well and enjoying the summer. Please feel free to leave any comments below good or bad ones!!

Welcome to Grenada

This is the start of my 3rd week in Grenada and the fact that I am only now getting a chance to write something is probably good testament to how busy I've been! The first 2 weeks were obviously alot of fun and luxurious, staying in the Coyaba Hotel right on Grand Anse Beach. It was sad seeing Amy and her Mum and Dad leave last Thursday but sort of marked the beginning of the next part of the elective. Once they had left, I moved into the apartment in Mont Tout, about 10 minutes walk up the hill, away from the beach. The photos here are the view from my apartment, and me outside Grenada General Hospital on the first day of the placement.

The hospital itself is a fascinating place. The staff and patients have all been very friendly although it is very evident that the healthcare set up here is way behind what we have at home in the NHS. I'm still finding it hard to get used to the idea that for many test, scans and procedures, patient's have to pay or leave the island to travel to Barbados, Trinidad or even the US. The basics are availiable free to the non paying patient but they really are basic tests eg. chest X-rays, simple blood tests. The lack of availiability of these things means that there is a much heavier reliance on clinical skills in diagnosing patients so it's been a good test of those skills. I've been based on the male and female general medical wards since I've arrived which are probably the 2 busiest wards in the hospital (there are approx 10 wards in total). In particular the junior doctors or 'interns' as they're called here have been very welcoming although it seems that in general the expectations of us as elective students are quite low. This is good in a way because they seem impressed any time you help out with small things such as taking blood samples, putting in intra-venous lines, reviewing patients, writing in the notes and running blood samples up the laboratory.

A typical day involves starting around about 8AM reviewing patients (how they have been overnight, any new symptoms etc) before the consulant round which starts at about 9, half 9ish and lasts 1-3 hours where all patients under the consultant's care are discussed, test results reported and managment plans drawn up. It's useful because Dr Noel (my supervisor) keeps the students on their toes by asking us questions eg. 'So Gordon, what do you think is wrong with this patient....' Err.... After the ward round there are normally lots of jobs to do on the ward and I keep busy with them and we normally finish up around time for a late lunch.

In general I'd say the first two weeks have been great, probably better than I expected. Gordon B seems to be enjoying it too which I'm pleased about. Part of what's made it so good is also the other elective students we've met, at any one time there are about 6 or us and so far we've had folk from Newcastle, Leeds, Glasgow and Southampton as well as us from Dundee. Hope everyone reading this is well and I'll try and put up some more posts from my elective here in due course...

Taking a Break...

<--- The beach in Barbados. (elective countdown - 5 weeks to go!)





Going to take a break from the blog for a month or so to concentrate on revision for finals, thanks for reading though!

May Review

Here are the most interesting articles / stories I've heard about from the BMJ in May:
- New consensus on screening has recommended that all patients over the age of 55 years should have a flexible sigmoidoscopy as part of the national bowel cancer screening programme. This could be done by doctors or specialist nurses. This test has been shown to catch two thirds of colorectal cancers.
- In Spain, surgeons worked for 24 hours to carry out the first 'full' face transplant.
- Regarding viewing the body after a traumatic death, relatives should be informed of the choice and given the option. The decision should rest with the relative.
- The national patient safety agency reports more than one incident in the past year where leaving a tourniquet on has led to people losing digits - beware!
- The Australuian government has decided to remove branding from all cigarette packaging as of 2012 to reduce marketing advertising of cigarette brands.
- A new way of labelling and packaging foods known as the 'traffic light system' is in the process of being passed through the European courts. Some supermarkets in the UK have already adopted the scheme but it is being held up at present by arguments that some foods which should be included from time to time as part of a balanced diet eg margerine / cooking oils.
- Screening again, a study was carried out recently to find out whether sending 'informed choice' letters inviting people to screening would lead to less uptake than the 'standard invitation' for screening. Informed choice tells people about some of the disadvantages of screening. The result was that there was no difference in the number of people who attended (approx 60%). What was apparent however was that the most significant marker of a person's likelihood to attend for screening was their socio-economic status.
- What will the legacy of the 2012 Olympic games be (and other major sporting events). New research shows that politician's promises of long term health benefits for the host nation / city are largely unfounded. Quality of evidence of health improvement is low, most measures are of economic improvements. With the 2012 games around the corner, perhaps more work should be done to evaluate the effects of the games.

Smoking in Pregnancy, Improving Outcomes from Surgery and Medico-Legal Cases

Last post from sunny Oban then its back to Dundee - only 4 more weeks of 4th year to go! The next two articles were sent from The Obstetrician & Gynaecologist - a publication from the Royal College of Obstetricians and Gynaecologists.

1) Smoking During Pregnancy
there is still a high incidence of smokers in pregnancy. Effects on the unborn child can be devastating. Smoking is still the single largest preventable cause of fetal and infant morbidity in the UK. Potential problems include placental abruption/praevia (3x greater risk), prematuire rupture of membranes, fetal growth restriction, ectopic pregnancy, intra-uterine infection, fetal growth restriction, sudden infant death syndrome etc. Motivational assessment, 'talking' therapy and one to one councelling are ways of helping mothers quit. The aim really is to empower the individual. Carbon monoxide tests can be used to assess maintenanct. Nicotine replacement therapy is best avoided in pregnancy because nicotine crosses the placenta. One way of helping people quit is to dispel any untrue theories mothers ay have eg. that a small baby is good because it won't hurt so much when its born. Perhaps eduction is the best way forward...

2) Improving Outcomes from Gynaecological Surgery
A cancer 'survivor' is someone who has 'completed the initial cancer treatment, is living with progressive disease before the terminal stages of illness or who has had cancer treatment in the past. Most gynae cancers are curable IF THEY PRESENT EARLY. In the majority of cases treatment-related morbidity IS PREDICTABLE. Major morbidities include: GI adhesions, bowel obstruction, chronic diarrhoea after radiotherapy, radiation cystitis, ureterovaginal fistulae, infertility, decreased sexual function, peripheral neuropathy and lymphoedema which can become severe. It is important to be aware of all of the potential sequelae of treatment but the majority of survivors can look forward to a good quality of life, supportive relationships and the many positive aspects of a continued life.

Also every 3 months the MPS sends its 'Casebook' magazine for members which at the back contains a series of medico-legal cases of recent interest. Here is one interesting case - a 30 year old man attends A&E after noticing a widespread skin rash. He has rheumatoid arthritis and is taking Methotrexate, however the junior doctor on call forgets to ask him what medications he is on and the patient doesn't reveal this info. The doctor correctly recognises that the man has chickenpox (varicella zoster viral infection) and sends him home. He feels worse and both out-patient phone services and the GP agree with the provisional diagnosis and tell him his symptoms will improve with treatment. He goes on to collapse at home, is taken to hospital and diagnosed with disseminated meningoencephalitis. Despite therapy with IV acyclovir, he dies due to multi-organ failure secondary to sepsis. The family made a claim against all aprties involved and the case was settled for a high sum.

Should the UK go for the "opt-out" of organ transplantation policy?

This topic seems to come up again and agina and was brought to my attention this week on a TV debate on BBCone. Although I've always been for the "opt-out" scheme which has been adopted in some coutries eg Spain, I started to see the ethical points raised by arguments AGAINST the proposals:

FOR the opt-out schmeme:
Saves lives, reduces waiting times for organ transplantations, beneficence (doing what's best for the patient needing the transplant) and justice (benefiting the greater good of the population) are just some of the points for.

AGAINST the opt-out scheme:
Loss of patient autonomy on deciding what is to be done with their organs following death, the danger of harvesting organs against family members of the deceased's wishes leading to distress, possibility of leading to an increase in mistrust in doctors about how organs are handled (I don't believe this) and also the loss of that sense of 'giving someone the gift of life' if organ donation becomes automatic.

The opt-out organ donation scheme was most recently reviewed in 2010 and will be reviewed again in the near future. Any scheme would need to come with aggressive advertising to allow people to opt-out of the scheme, however I beleive that before jumping to this more should be done to get people registered to opt-in. I'd like to see GPs asking patients, schools requiring all leavers to register their wishes or people passing their driving tests to register (although I think this may already be being done).

Should we sterilise drug addicts?

Things I'm reading at the moment:
Should we pay drug addicts to become sterilised? - Doc2Doc Discussion. The idea is a financial incentive to encourage drug addicts to either become sterilised, or to take up long term methods of contraception. An ethical dilemma.
For - Babies born to drug dependent mother's have a very difficult start to life.
Against - Depriving someone of their human rights. Not ethical to offer sterilisation when more short term alternatives are avaliable. Does including a financial incentive impede the user's ability to consent? Sterilisation of drug addicts, then where do you stop? Patients with heritable diseases?

A Career in Dermatology - Student BMJ
An article in the journal gives a further insight into dermatology as a potential future speciality. To become a consultant dermatologist the typical route is to finish foundation years, then enter either core medical training or acute care common stem (take MRCP part 1 exam minimum), then apply for a specialist training post in dermatology (ST3 level). These posts are highly competitive and often candidates have a PhD or MD. Specialist training lasts for 4 years. Things that can be done right now: get undergraduate experience, enter essay competitions and get involved in research.

Also...
Is Modern Genetics a Blind Alley? - BMJ
The Academic Foundation Programme - Student BMJ
Is ADHD a valid diagnosis in adults? - Student BMJ

Diagnosing Death, Thyroid Disease and Medical Eponyms

<---Sunrise, Mt Sinai, Egypt. June 2009

Diagnosing Death - from the BMJ Podcast (16/04/10)

Dealing with death is probably one of the hardest things to cope with as a junior doctor, particularly if you are being faced with it for the first time. Here are a few tips on how to manage the situation:

Verify the death - check patient identity, observe patient appearance and note absence of any respiratory movements (over a 5 minute period). Auscultate over the chest and listen for heart/breath sounds. If any activity at all, reassess for a further 5 minutes. Check corneal reflexes, pupil response (reflexes) - pupils will be dilated and non-responsive. Check motor response (apply supra-orbital pressure) Check for pulses - carotid (both sides), radial and femoral. Wash hands. Make an entry in the patient's notes - date and time of death, findings on examination.

Breaking Bad News - Step back, take a deep breath, don't rush into the situation, think about your management plan. Communicate with family members, next of kin, what has happened. Do this in a private, quiet place eg. relatives room (clean and representable). Don't keep people waiting, turn off phone, pager etc and ensure NO interruptions. Use lines eg. "I'm sorry to say we have some very bad news". Use terms dead / died, as opposed to 'passed away', 'deceased' etc. Avoid common euphemisms. Discuss practical issues eg what will be done with the body, how the body is laid out. Inform the GP of the death.

Consider need for a post-mortem / referral to the procurator fiscal eg cause of death is uncertain, suspicious, accidental, violent, due to surgery/anaesthesia. If there is any cause for concern / suspicion, do not complete the death certificate - instead, discuss with a senior colleage.

Complete a death certificate. Ask yourself, am I the best person to complete this certificate? Legally someone can only complete a death certificate if they have seen the patient in the past 14 days. You MUST see the body after death. Once it is completed, it should be taken to the registrar of births and deaths (usually by the patient's next of kin). If there is any doubt, discuss with senior colleagues before proceeding.

Some OnExamination question corrections:
Differential Diagnosis - Thyroid Disease:
deQuervain's Thyroiditis - most frequently seen in young females. Often follows a flu-like illness. The patient commonly reports pain and a tender thyroid gland. It is usually a self-limiting illness.
Follicular Carcinoma - spreads haematogenously to the lungs. Treatment is with a total thyroidectomy. It presents with a firm neck nodule.
Anaplastic Carcinoma - rapid onset growth of a hard, woody thyroid lump which eventually progresses to acute dyspnoea. Abysmal prognosis.
Hashimotos's Disease - the commonest cause of primary hypothyroidism. Usually presents with signs of myxoedema. On examination there is a diffusely enlared non-tender thyroid gland.
Multinodular Goitre - may be asymptomatic or may present with pressure symptoms eg. dysphagia, dyspnoea or hoarseness. Particularly endemic in areas with iodine deficiency.

Medical Eponyms:
Rovsing's Sign - RIF pain exacerbated by pressing in the left iliac fossa (bowel is pushed onto the inflamed appendix) - classic in appendicitis.
Courvoisier's Sign - Law that states that in the presence of painless obstructive jaundice if there is a palpable bladder then the cause is unlikely to be gallstones.
Grey-Turner's Sign - Bruising of the flanks seen in retro-peritoneal haemorrhage.

Tumour Markers:
Carcinoembryonic antigen (CEA) is a commonly used tumour marker in colon cancer.
alpha FP and bHCG are markers raised in testicular cancer.

Engagement!

No post this week, Amy and I have just got engaged! Absolutely thrilled, so great to share it with both our families up in Dundee and with friends. Thanks to everyone for today!

Education Articles from the Student BMJ April 2010

Vitamin D deficiency

Causes Rickets in children and osteomalacia in adults. More than 50% of adults in the UK reportedly have a deficiency in vitamin D and the highest rates in the UK are in Scotland. Vitamin D is sourced from sunlight and from 1,25 dihydroxyvitamin D3 (calcitriol). Vitamin D status is best determined by assay of serum 25-hydroxyvitamin D (25-OHD). Vitamin D deficiency is associated with increased mortality and increased risk of common conditions such as cancer, cardiovascular disease and type 2 diabetes. Anyone who lives in a northern latitude country has an increased risk of vitamin D deficiency. At these latitudes, pigmented skin is also a risk factor.

Children: may present with bony deformity (Rickets), bowing of the legs (genu varum), irritability and reluctancy to weight bear. Height is more affected than weight. Management is with oral calciferol or colecalciferol to relplenish vitamin D stores.

Adults: present with proximal muscle weakness, bony pain, muscular aches, muscle weakness. Dif dx - fibromyalgia. Hypocalcaemia and hypophosphataemia may be present. Treat with calciferol.


Minor Eye Trauma

This was really a revision article in the student BMJ this week regarding the most common eye injuries which a junior doctor should have an idea about how to manage. Must rule out a head injury and must assess vision in both eyes and document this (legal requirement).

Corneal Abrasion - symptoms of intense pain, a watering eye and foreign body sensation with a clear history of a scratch / trauma eg 'A twig hit my eye'. To look for corneal abrasions, stain the cornea with flourescein dye. Treat with oral analgesics and topical antibiotics (sparingly because they delay wound healing).

Corneal, conjunctival and sub-tarsal foreign bodies
Feeling of 'something in my eye', symptoms of watering, red eye, pain, photophobia and FB sensation. Normally vision is unaffected. Metallic FBs leave behind a 'rust ring'. Examination should include eversion of the eyelids. Irrigate the eye using saline. Removing a FB usually requires a slit lamp and should be left to an opthalmologist.

Traumatic Subconjunctival Haemorrhage
Bleeding from the conjunctiva or episcleral blood vessels into the subconjunctival space. The eye is usually asymptomatic. If no co-existing injury the patient can be reassured. The blood usually disappears in 1 - 2 weeks.

Blunt-Eyeball trauma
eg. from squash balls. Can cause hyphaemas, retinal, choroidal tears, bony fractures. If vision is impaired - see an opthalmologist immediately. A fracture implies a severe injury.

Blow-Out Fracture of the Orbital Floor
Often occurs when a large object hits the face, commonly during sport or an assault. Patient may complain of diplopia, epistaxis, cheek numbness and a desire to blow the nose (which should be avoided). Assess ABC, rule out a head/neck injury and control any epistaxis.

Breast Cancer Screening Debate

Breast cancer screening debate

Is screening for breast cancer as effective as was previously thought in identifying disease? A study released this week put to bed some rumours that more people are treated un-necessarily than are helped by screening, showing that for every 2 people correctly identified and treated for breast cancer, one is treated un-necessarily.

Breast Cancer Screening

On the other side of the debate, this article from Denmark, reported in the NHS news says that the benefits are not as great as were previously thought.

Breast Screening Benefits Not Obvious

Then on the other hand there's the fact that at present, breast screening and mammograph is a very uncomfortable process, I was able to feel first hand how much pressure is necessary for a good image by putting my fist in a mammography screener and I remember being surprised as to how hard it presses down.

Perhaps the answer is more self-screening at home, I wonder how many people actually do this, it would be interesting to see what the uptake is like in Tayside (I predict quite low). Should breast examination be more routinely carried out as a physical examination in women age 50 - 70? Again I don't think most women of this age on a medical ward in Ninewells have this examination.

Sir James Black Obituary

This picture is of red blood cells leaking from a damaged blood vessel. It was one of the winning pictures from the Wellcome Trust Image Awards 2008.

Last week saw the passing of Sir James Black, a truly remarkable Scottish scientist whose discoveries saved the lives of millions of people. He won the Nobel Prize for Medicine in 1988 and was chancellor of the university of Dundee from 1992 until 2006.

Some of his key drug discoveries included beta blockers and cimetidine for peptic ulcers which were for many years the world's biggest selling drugs. He studied medicine, and graduated in 1946 after which he joined the physiology department at the university of St Andrews. He began at to pursue an academic medical career. Initial research focused on blood flow related to rates of intestinal absorption by specific cell receptors of various substances. By 1956 he had set the goal of developing cell receptor modulators for various disorders but it was in 1963 at the university of Glasgow that he discovered propanolol and the role of beta receptors in controlling heart rate. He described winning the Nobel Prize as "the most exciting week I ever had" and the same year founded the James Black Foundation, a non-profit group of scientists engaged in new drug research. A truly remarkable man.

Also I have to say that I'm loving the BBC's "Wonders of the Solar System", hosted by 'the rockstar physicist' Professor Brian Cox, at the moment!

Cold Turkey, Blue Nails and Minimum Pricing.

Quick post this week - 4th year just seems to get busier by the week! This week I was reading the student BMJ (March) in which there were several interesting articles. Minimum pricing of alcohol was discussed, this seems to be an ongoing debate and will almost certainly have an important bearing on the next general election. I am definitely of the opinion that in the next 5-10 years there will be a massive change to the way in which alcohol is sold and consumed in the UK. The figures in Tayside alone show the scale of the financial burden to the NHS and the days of heavy boozing may soon be a thing of the past (good job my student days are nearly over then!).

The front page article on this month's student BMJ was regarding stem cell research however I've talked enough about this in previous posts (see below). Also covered in this month's journal was an insight into some disciplines which I previously had not known were present in the hospital. They are the critical care outreach teams and the bereavement officer. The critical care team can be contacted if there is a situation on the ward where a patient's state is deteriorating, presumably contactable at night, therefore it should never be the responsibility of a single doctor to manage a patient's care, nor should the doctor feel alone in this situation.

A moment for teaching: Wilson's Disease. This is an autosomal recessive inherited disorder of copper metabolism. Patients with this condition have impaired copper excretion and metabolism. Clinical signs of the disease are: eye signs (Kayser-Fleisher rings, extra-pyramidal disorders of movement eg. dystonia, psychosis and cirrhosis of the liver. Rarely the nails may appear to be a blue colour due to the effect of the copper.

Finally, there is recently published evidence that most quitters infact stop smoking without the need for additional support. Apparently often these patients are left out of trials and studies, partly because the research is not sponsored by any of the drugs companies which manufacture aids to help patients stop smoking.

Blood Pressure Variability

One of the big things which hit the health news headlines this week was the report that patients with 'occasionally high' blood pressure are at greater risk of developing a stroke than those with consistently high blood pressure. Management of hypertension is a vital aspect of preventative medicine, particularly in a primary healthcare setting. I'm seeing this alot at the moment most likely because I'm half way through a 4 week GP placement. The article appeared in The Lancet this week and a review was published today:

Limitations of the usual blood-pressure hypothesis and importance of variability, instability, and episodic hypertension Volume 375, Issue 9718, Pages 938 - 948, 13 March 2010

The argument is that up until now, sporadically increased episodes of blood pressure have been ignored and too much focus has been on "widespread belief that underlying usual blood pressure can alone account for all blood-pressure-related risk of vascular events". In fact clinical guidelines recommend that episodic hypertension is not treated. At the moment the NICE guidelines on management of hypertension are currently being re-written and no doubt this new evidence will play an important part in new recommendations.

On Doc2Doc there was a post from the author of the site about parking charges for hospitals, it seems that in Dundee we are not alone in having to pay for parking! In some hospitals there are monthly rates of £50 or more.

A case recently saw a doctor being taken to court for refusing to pay a £10 parking fine 'on principle' for parking in an illegal space whilst on duty. The article seems to focus alot on doctors but doesn't talk about the barrier's this poses to patients coming to the hospital which is probably more of a concern. With failure rates at appointments running at an all time high and constant chat about "increasing productivity and efficiency within the NHS to save costs" this is surely the kind of thing which needs to be looked at.

Differential Diagnosis, Doctor's Handwriting and Medicine Beyond the 9 to 5

Tom Yeoman, one of the 5th years at Dundee at the moment wrote an interesting article in the Lancet Student this week which caught my attention (Not the Flu - March 2010). He describes reports of patients being diagnosed with having swine flu who have ended up being treated from a range of conditions including appendicitis, malaria, acute myeloblastic leukaemia and meningococcal meningitis! It just goes to show that it's always important to think about the differential diagnosis even if the cause seems obvious. Whenever we write up case reports, we always list the differential diagnosis and this is the reason why, to rule out the alternative causes through methods such as investigations. In the cases of swine flu, due to the possible diagnosis of swine flu this patient had not been given a full assessment by the GP.

Reading on doc2doc this week, the medical professionals forum posts included doctor's handwriting - where a study carried out by Diabetes UK found one in six case notes to contain errors in written notes, and a guy who asks the question 'Why is Transgender still classed as a Mental Disorder'. This does seem to be medicalisation of a choice that someone might make and surely does not mean to imply that they have a mental health problem. I guess it comes back to that question which I posed earlier as to whether completed suicide implies that the person had a mental health problem. Homosexuality was deleted from DSM IV in 1973. Another article asks the queston, Would you change career after medical school? I answered yes. To tell the truth I am feeling a bit disillusioned at the moment, the same phrases do seem to be coming up alot 'burn-out', 'don't do it' etc. But a respondant put in a good quote afterwards:

“…Medicine arose out of the primary sympathy of a man with man; out of the desire to help those in sorrow, need and sickness”. …

-Sir William Osler, “The Evolution of Modern Medicine”, Yale University, April 1913.

Perhaps I need to remember this, although I do wonder if there are other ways I can help. The Dundee University Medical School MSC Symposium this week is titled "Medicine - Beyond the 9 to 5". I'll try and get along to some of this, it might give me some ideas!

BMJ Articles - February 2010

BMJ Podcast - 01/02/10

Treatment of Clubfoot

· Many children suffer from clubfoot.

· Hippocrates wrote the first account of this in 400B.C.

· Most common historical technique for correction – extensive surgery or manipulative techniques. Often associated with stiffness and an associated limp in later life.

· Achilles Ternotomy – Ponsetti’s method is a new cheaply and easily carried out.

· Effective rehabilitation requires the parents to be motivated.

· 90% of children can expect a successful outcome – a pain free foot.

· Children essentially crippled for life can be ‘cured’.

Sharing health research data – research methods and reporting

· Why should researcher’s share their data? People should consider that if they have data they are not using, perhaps they could make it avalible to other people rather than having ‘lost’ data.

· Although studies are often very anonymised but if there is a large data set then it may be possible for patients to identify themselves.

· Come up with a list of 28 identifiers that researchers should take great caution about when releasing data set. These are ‘indirect identifiers’ which may lead the patient to identify their own data.

· Could data sets be shared after a period of ‘fair use’ is information is not published? Patients need to be told about this to give consent.

BMJ Podcast – 05/02/10

Urinary Tract Infections

· Managing these in primary care. This is a common disorder but new research has shed light on a well known condition.

· UTI is one of the commonest acute presentations in primary care.

· Majority are bacterial – usually treated by antibiotics.

· Commonest management is an immediate antibiotic prescription. Gold standard is mid-stream urine sample.

· Urinary dipsticks are also used to diagnose.

· Empirical delayed prescribing of antibiotics.

· Main outcome measure was severity of symptoms in a diary. There was no significance on severity of symptoms in all of the management approaches above. Demonstrated a 20% reduction in antibiotic prescribing.

· Triad of papers - trial / economic analysis / qualitative survey.

· Antibiotic resistance is relatively common in urinary tract infections.

BMJ Podcast – 12/02/10

Prescribing SSRIs with Tamoxifen

· New research shows that these drugs, prescribed together is not safe and leads to an increased risk of death.

· SSRIs interfere with the metabolism of Tamoxifen.

· This used to be a theoretical drug interaction but has now been quantified by a research institution in Toronto.

· Paroxetine was the SSRI involved in the trial and it is an irreversible selective serotonin re-uptake inhibitor.

· Patients should take care not to suddenly stop their Paroxetine.

· They should swap to another antidepressant.

Most medical school in the USA lack rules on ‘ghost writing’.

· Ghost writing is the practice of drug companies presenting a paper to academics and asking them to put their name to a paper they have not actually written.

· Reported authorship is essential for research integrity.